MEDICARE: CROZET BLUE RIDGE DENTAL, PLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	1223G0001X	General Practice Dentistry

General Provider Information

NPI Number	:	1780364026
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CROZET BLUE RIDGE DENTAL, PLC

Provider Business Mailing Address
First Line	:	19810 W CATAWBA AVE STE A1
Second Line	:
City	:	CORNELIUS
State	:	NC
Zip	:	28031-4056
Country	:	US
Telephone Number	:	704-997-8878
Fax Number	:

Provider Business Practice Location Address
First Line	:	5405 ASHLAR AVE APT 102
Second Line	:
City	:	CROZET
State	:	VA
Zip	:	22932-1587
Country	:	US
Telephone Number	:	434-823-2385
Fax Number	:	434-823-2978

Authorized Official
Title or Position	:	DIRECTOR OF NETWORK RELATIONS
Name	:	JESSICA HUNTER
Credential	:
Telephone Number	:	704-780-4597

Provider Enumeration Date	:	07/21/2023
Last Update Date	:	04/09/2026

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